Putting People First

Transcription

1 Putting People First Primary Health Care Plan for Auckland City

2 Putting People First ACKNOWLEDGEMENT The diagram above is adapted from Our Lives in 2014, the Blueprint and the Strengths Care Plan. It shows a person surrounded by all the social supports and health services they need for good mental health. This is what we want for people resident in the Auckland District Health Board area. Suggested citation: Auckland DHB (2009) Primary Health Care Plan for Auckland City Auckland City: Auckland District Health Board. Further copies can be downloaded from Published: June 2009 by Auckland District Health Board, Private Bag 92024, Auckland Mail Centre, Auckland 1142 Copyright reserved Permission is given to freely copy and to distribute this report provided that no charge shall be made. Information within the report may be freely used provided the source is acknowledged. Whilst every care has been taken in the preparation of the information contained in this report, no responsibility can be taken for the results of any act or omission based on the information supplied.

3 Mihimihi E nga mana, e nga reo, e nga karangarangatanga tangata Ko te Toka Tu Mai o Tamaki Makaurau tenei E mihi atu nei kia koutou, Tena koutou, tena koutou, tena koutou katoa. Ki a tatou tini mate, kua tangihia, kua mihia kua ea Ratou, kia ratou, haere, haere, haere. Ko tatou enei nga kanohi ora kia tatou Ko tenei te kaupapa, Hauora Maori, o Te Toka Tu Mai Hei huarahi puta, hei hapai tahi mo tatou Hei oranga mo te katoa. No reira tena koutou, tena koutou, tena koutou katoa.

4 Foreword Ko Pokopoko ko Kahukura ngā Taniwha Ko Rangiriri Te Rākau Whakangau Tai Ka rere te tai tapu Ki te panekeneketanga o ngā waka ki roto i te Kaipara Ki Taporapora, tahuri waka whakarere wahine Puta atu ki waho ki te moana nui o Tāpokopoko-ā-Tāwhaki Nā Ngāti Whātua i whakahua Ko Māhūhū ki te Rangi te waka Ko Rongomai te Ariki Ko Ngāti Whātua te iwi R. Naida Glavish J.P. Tihei Mauri Ora Te Runanga o Ngati Whatua and the Auckland District Health Board signed a Memorandum of Understanding in 2001 in order to recognise and respect the Treaty principles which establish a relationship between Maori and the Crown based on the concept of partnership. Since recording our mutual commitment with Auckland District Health Board, we have both grown in our understanding about the way our respective Governance and operational structures need to interact with each other and how our ongoing relationship can help facilitate the outcomes we both seek. We firmly believe that a joint sign off of the Primary Health Care Plan is an appropriate recognition of our role in the achievement of health gains and that we each have sufficient confidence in our collective ability to achieve our mutual aspirations. I am greatly encouraged by the spirit in which our discussions about this plan have been held and the efforts of our organisations to uphold the commitments we originally made to each other. I look forward to the achievement of the goals that this plan seeks to bring to us all. R. Naida Glavish J.P. Chairperson Te Runanga o Ngati Whatua 4 Auckland District Health Board

5 This plan represents a new milestone in relationships with our PHOs and Te Runanga o Ngati Whatua. It is the first time that we have achieved a truly joint collaboration in the formation, testing and eventual endorsement of our primary care planning. What s more, it is indicative of a new and more sophisticated way of working as a District Health Board. Pat Snedden DHBs are about the whole of health provision in their area. Primary care represents a huge chunk of the health provision activity that happens in our rohe. It only makes sense that we involve, test, evaluate and change what we do. We now have a dynamic relationship with primary care providers that goes well beyond the confines of the commercial contracting. That s why we are inviting PHO clinical and management representatives onto our senior management structure. There are challenges with this interface but not ones from which we wish to shrink. This plan truly advances primary health care for the people of Auckland. The people in our area deserve quality first point of contact services. In fact, over the next twelve years we want to build a world-class system. That s a lot to ask of our general practitioners, practice nurses, community health workers, midwives and the primary health organisations that represent them and also the secondary services that they link to. We see primary health care as incorporating front-line doctors and nurses, community-based health workers, dentists, pharmacists, kaupapa Maori health providers and our Pacifica nurses working in their communities. The success of this plan rests on our ability to develop good relationships. Relationships that run across all the many boundaries within health. This plan will ensure that Maori health is improved as a priority. It is not acceptable that some groups in our city have poorer health status and poorer access to services. The other important relationship is across primary and secondary care. In reality people need their GP to manage their health and to make sure that, when necessary, there is a smooth transition to and from hospital services. We have some real barriers to break down here. This plan promises a lot. It can be achieved by an across the board commitment to work together. It can be as simple as that. The Auckland DHB and my role as Chair will provide the leadership for this work and the vision of quality primary health care for all. Pat Snedden Chairperson Primary Health Care Plan for Auckland City

6 Our primary healthcare partners We support the principles and directions of the Primary Health Care Plan and will work with Auckland District Health Board towards ensuring successful implementation of the Plan. Mr. Henare Mason Chairperson Tamaki Healthcare PHO Mr. David Hunter Chairperson ProCare Network Auckland PHO Mr. Rea Wikaira Chairperson Auckland PHO THE TONGAN HEALTH SOCIETY (Inc) Ko e Sosaieti Tonga ki he Mo ui Lelei Mr. Malakal Ofanoe Chairperson The Tongan Health Society (Inc) Dr. Joe Williams Chairperson Auckpac PHO 6 Auckland District Health Board

7 Table of Contents Treaty of Waitangi Statement 8 Section One: Setting the Scene 10 Introduction 12 What Is Our Aim? 13 What Is Primary Health Care In This Context? 13 Key Principles 14 Section Two: Building Our Understanding 16 Information about People Who Live In Auckland City 18 Updated Data on Our local Maori Population 21 Addressing Health Inequalities 22 What Services We Currently Have 23 What People Are Telling Us They Want 24 What Evidence Is Telling Us 25 Section Three: The Way Forward 26 Our Commitments 28 Section Four: Evaluating Our Progress 46 What Does Success Look Like? 48 Section Five: Who has been involved? 50 The Working Group 52 The Steering Group 53 Engagement with Partners 54 Community Engagement to Date 54 Written Feedback Received 55 Appendices 56 Appendix 1: Doing more in primary care to help people with mental health and addiction issues Appendix 2: An integrated approach to the prevention and management of long term conditions References 62 Primary Health Care Plan for Auckland City

8 Treaty of Waitangi Statement Auckland DHB recognises and respects the Treaty of Waitangi as the founding document of New Zealand. The Treaty of Waitangi is the fundamental relationship between the Crown and iwi. It provides the framework for Maori development, health and wellbeing. The New Zealand Public Health and Disability Act 2000 requires DHBs to establish and maintain processes and measures to enable Maori to participate in, and contribute towards, strategies for Maori Health improvement. The measures are a response to the Crown s desire to have greater Maori participation in the health and disability support sector with a view to improving Maori health outcomes, and reducing health disparities between Maori and other population groups. The measures also reflect the Crown s overall partnership with Maori under the Treaty of Waitangi and its commitment to protecting Maori health. The measures include: minimum Maori membership on boards of DHBs provision for Maori membership of DHB committees training for board members to ensure they are familiar with Treaty issues, Maori health issues, and Maori groups or organisations in the DHB a requirement for DHBs to establish and maintain processes to enable Maori to participate in and contribute to, strategies for Maori health improvement a requirement that DHBs continue to foster the development of Maori health capacity for participating in the health and disability sector and for providing for their own needs an expectation that DHBs provide relevant information to Maori to enable effective participation. This legislation recognises and respects the principles of the Treaty of Waitangi in order to improve health outcomes for Maori. References to the Treaty of Waitangi in this document derive from, and should therefore be understood in, this context. As a Crown Agency, Auckland DHB will demonstrate how Treaty responsibilities are managed within the health sector by our commitment to the principles of partnership, participation and protection. These principles are outlined by the Ministry of Health to provide direction to the health sector and form the basis of the Auckland DHB Te Tiriti O Waitangi Policy. Our Commitment to the Treaty of Waitangi Our Treaty relationship is with Te Runanga O Ngati Whatua through a formalised Memorandum of Understanding. This Treaty partnership is operationalised within Auckland DHB through the Maori health purchasing organisation (MaPO), Tihi Ora. Further relationships and arrangements with other iwi groups and Maori communities residing in the Auckland DHB will be developed and strengthened. If firm relationships with iwi and Maori communities are in place, then this provides a sound platform to lift the health status of all Maori in the Auckland DHB area. 8 Auckland District Health Board

9 Treaty Principles in Action Partnership Te Runanga o Ngati Whatua as manawhenua, is a partner with Auckland DHB at the governance level Memorandum of Understanding with Te Runanga o Ngati Whatua and its health operational arm Tihi Ora MaPO Ngati Whatua, as the manawhenua partner with Auckland DHB at the governance level. This actively protects Maori interests in health planning and funding Auckland DHB has a Maori Health Advisory Committee Consultation with Iwi Maori in planning health and disability services and regarding service and other changes. Participation Maori engagement in planning, development and delivery of health and disability services Responsible and responsive to Maori communities in our district and those who use our services Active involvement of manawhenua and mataawaka communities in identifying health needs, in providing health services and in our plans to improve health and disability services Engagement with Maori regarding the impact that service and other changes may have on Maori communities and organisations Assistance to further develop Maori providers in our district. Protection Equity of participation, access and outcomes for all Maori Maori enjoy the same level of health as non- Maori Safeguard Maori cultural concepts, values and practices Adhere to the Auckland DHB Tikanga Best Practice Policy to protect the rites/ rights of Maori, respect the tikanga of manawhenua and practically contribute to providing services that are responsive to Maori needs and interests Services will meet the rights/ rites, needs, interests and aspirations of Maori There is commitment to the Maori Health Strategy, He Korowai Oranga and other national policy Use of the health equity assessment tool (HEAT) Also the ADHB Prioritisation Framework (based on the national prioritisation framework), which incorporates whanau ora into decision making. Primary Health Care Plan for Auckland City

10 Section One: Setting the Scene

11

12 Introduction Auckland District Health Board (ADHB) has signalled an intention to broaden its approach to incorporate both the wider healthcare system and consideration of the determinants of health into its remit. There has been a move to develop stronger relationships with other agencies and organisations whose work also impacts on health. This plan supports this broader approach and focuses on primary health care. ADHB would like to provide a supportive environment for primary health care to develop. ADHB and the Primary Health Organisations (PHOs) in the ADHB district have been making progress on the implementation of the NZ Primary Health Care Strategy PHOs are well established, most people are enrolled with a PHO, and changes have been affected in funding mechanisms to better support the implementation of the Strategy. It is now time to take stock and determine how far the six key directions of the Strategy have been achieved. The directions are: work with local communities and enrolled populations identify and remove health inequalities offer access to comprehensive services to improve, maintain and restore people s health coordinate care across service areas develop the primary health care workforce constantly improve quality using good information. We now see the opportunity to progress these directions more quickly as part of a commitment to developing a world class primary health care system for residents of Auckland City. This plan will focus on keeping people well - a stance consistent with the DHB imperative to Lift the Health of People in Auckland City. We want all parts of the health care sector to contribute and work together to achieve this goal. Primary health care services are well placed to help people to live as independently as possible and with a good quality of life. A large number of primary health services exist at present and we acknowledge the great work done by all who work in these services. This work is the core business of the DHB, and where we can affect most change for the benefit of the people of Auckland City. We also need to foster much greater involvement of non-governmental Organisations (NGOs) and public health services with primary care services. The Plan has been: Developed drawing on the views of the community, key partners (please refer to the list of participants, pg 54) and current literature about primary health care; Refined by drawing on feedback and ideas gathered during consultation, and Approved by the Auckland DHB Community and Public Health Advisory Committee (CPHAC), Te Runanga o Ngati Whatua and PHO Boards. There could be neighbourhoods in the city that are being overlooked (such as the central city area). How are they being catered for? (Mt Albert Public Meeting) 12 Section One: Setting the Scene

13 Links With Other Plans This plan fits well with other pieces of work, many of which highlight the strategic change signalled above, including the New Zealand Primary Health Care Strategy, He Korowai Oranga, and all ADHB Strategic and Operational Plans, including the Auckland DHB Maori Health Action Plan Te Aratakina A pathway forward, and Pacific People s Healthy Village Action Zones Framework. What Is Our Aim? What Is Primary Health Care In This Context? The aim is to offer the people of Auckland City a quality primary health care service that achieves wellbeing for everyone and forms part of an integrated, total health care system. We want primary health care services better integrated at local/neighbourhood level, as a means to work better with local communities. These aims require putting people at the centre of healthcare. Proposed Governance Oversight ADHB and our PHO partners will establish a governance structure to oversee the implementation of this Plan. Regular reporting will be provided to the Auckland Board/Community and Public Health Advisory Committee, Te Runanga o Ngati Whatua, and each of the PHO Boards regarding our progress and achievements. The World Health Organisation s Alma Ata defines primary health care as essential health care, made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. The Alma Ata approach states that primary health care is an integral part of both the country s health system, of which it is the nucleus, and the overall social and economic development of the community. It is provided in the spirit of self reliance and self determination. This is the spirit in which we have written this plan. Drawing on this definition, the key characteristics of high-quality primary health care service, is that it is a practical, affordable, equitable, scientificallysound, universally available, first point of access to health care in a community. Primary health care encompasses a continuing-care process over the life course of individuals and their families. Services include health promotion, disease prevention, screening, health education, diagnosis and treatment, disease management and triage to specialist services. We understand that the scope of this definition includes the involvement of communities in developing their own strategies to improve health. We also appreciate that health gain is achieved through intersectoral action, which addresses the social and economic determinants of health, and action within health and disability services themselves. One of our key commitments is to build neighbourhood approaches. This approach is what we consider intersectoral action is at a local level. The DHB s capacity to act is most closely linked to existing contracted primary care and other providers. Within the scope of our mandate, the DHB intends to work through all available avenues, strengthening community participation as a foundation principle. Primary Health Care Plan for Auckland City

14 Key Principles Over the next 12 years we seek to develop and support primary health care services that focus on the health of the community, and will strive to improve the health status of that community within the constraints of the resources available by using the following principles: Te Tiriti O Waitangi will be honoured Addressing health inequalities will be a priority People will be partners in managing their own health and that of their community A population health focus/approach will be fostered Services will aim to be accessible, appropriate, affordable and timely We will build on what is currently working Performance will be measured Primary care will be the coordinator of a comprehensive response at all levels Changes will take into account work across the Auckland region 14 Section One: Setting the Scene

15 Photographs of the community garden project in the Auckland suburb of Owairaka. Primary Health Care Plan for Auckland City

16 Section Two: Building Our Understanding

17

18 Information about People Who Live In Auckland City Characteristics of the Auckland DHB population Aucklanders, as a group, tend to have a relatively good health status compared to New Zealand as a whole. However, there is room for considerable improvement, particularly in inequality reduction between groups within our population. In terms of protective factors, Aucklanders tend to eat healthier food. People who are overweight or who have high blood pressure are less common in Auckland than in New Zealand overall. Aucklanders also smoke less tobacco, are less likely to smoke marijuana and have slightly lower hazardous drinking habits. However, we exercise less and have slightly higher cholesterol levels. Men in Auckland have a higher incidence of all risk factors than women. They smoke more tobacco and marijuana, have higher cholesterol levels, are more likely to be overweight and to have poor diet. They are much more likely to drink alcohol in a hazardous manner. However, they do tend to get regular exercise more often than females. There are also large differences across ethnic groups. Maori in Auckland are more likely to smoke tobacco and marijuana, to have higher blood pressure, to be overweight, and to drink alcohol in a hazardous manner. Pacific people are far more likely to be obese, smoke tobacco, and have a relatively poor diet. At the other end of the spectrum Asian people have lower risks for all the indicators except regular exercise. However, this grouping hides other communities, such as the Indian community, who are likely to have the highest rate of cardiovascular disease of all. In terms of how people assess their own health status, there is a direct relationship between age, gender, ethnicity and income. However, for all ethnic groups, except Pacific people, self-reported health status was higher than the national average. Those who are poor have the lowest self-rating scores for health. Females in general assess their health as better than males, except in the areas of disability and mental health. Disability is experienced by 22% of the population. The rate of disability increases significantly with age, particularly in the population 65 years and older. The most common types of disability are mobility, agility and hearing. In 2005, people living in Auckland City had the third lowest mortality rate among all the Auckland DHB areas. But again there are inequalities. On average, males die younger than females by at least nine years but for both genders the rates are improving. For all ethnic groups, mortality rates in the Auckland DHB area are lower than the whole of New Zealand, and are improving faster. However, the non-maori, non-pacific, groups had 70% of their deaths after age 75 years compared to only 25% for Maori and 34% for Pacific people. There is not enough information about where good health advice is available in NZ. Some people (particularly those new to New Zealand) may not have the insight to know where to find a good GP, or to know where or who to ask for assistance. (Grey Lynn Focus Group) 18 Section Two: Building Our Understanding

19 Demographic Information Auckland City s population is expected to grow at a rate of 1.7% per year until 2011 (medium projection). The Census 2006 suggested that the number of people aged 65 years and older living in Auckland City was just over 40,000. This number is expected to grow by 94% reaching about 78,000 in year Auckland City Population, Census 2006 and Projection Year Population Population increase ,310 Growth from ,296 35, % ,121 34, % ,850 34, % ,844 33, % The population of Auckland City is young, with more than half the population in the year age group. Many of our children (41% of all 0 4 year olds) live in the most deprived areas of the city. Ward Auckland DHB Ward, Census 2006 Ethnicity and Deprivation Population % Ward % Maori % Pacific % Asian % Indian % Others %Most dep Avondale Roskill 96,913 23% 20% 29% 33% 46% 17% 38% Hobson 84,240 20% 9% 3% 32% 9% 23% 23% Western Bays 41,286 10% 9% 8% 3% 3% 12% 10% Eastern Bays 48,682 11% 8% 3% 9% 3% 15% 8% Tamaki- 86,688 20% 39% 46% 20% 26% 13% 56% Maungakiekie Eden Albert 61,374 14% 12% 10% 2% 13% 18% 27% Hauraki Gulf 9,148 2% 4% 1% 0% 0% 3% 52% Islands Total Auckland City 428, % 100% 100% 100% 100% 100% 31% Please note these percentages are rounded to 100%. The most populated areas in Auckland City are the Tamaki-Maungakiekie and Avondale-Roskill wards with 23% and 22% of Auckland s population respectively. Most Maori and Pacific people live in the Tamaki-Maungakiekie ward 39% and 46% of their populations respectively. Most Indians and Asians live in the Avondale-Roskill ward 46% and 33% of their populations respectively. The other populations are fairly evenly distributed across all Auckland wards. Empowerment is great. Knowledge is power so need to educate at every level. (Remuera Focus Group) Primary Health Care Plan for Auckland City

20 Review of the epidemiology Chronic pain, asthma, arthritis, ischemic heart disease and mental health problems, are the major contributors to long-term conditions seen in the Auckland City population. Prevalence of Major Chronic Diseases in Auckland Chronic conditions Percent Number Asthma ,306 Arthritis ,196 Ischaemic heart disease ,684 Dementia 7.7 3,113 Chronic obstructive pulmonary disease ,907 Depression ,726 Diabetes ,532 Stroke and mild stroke (TIAs) 1.5 5,111 Epilepsy 1.4 5,665 Total cancer since 1994, excluding deaths 7,550 Total 215,790 Three-quarters of all deaths in Auckland City are due to diseases related to the circulatory system (39%), cancer (27%) and the respiratory system (8%). All of these conditions are important contributors to long-term conditions. In addition, there are a range of risk factors that contribute to the development of long-term conditions, or can be considered a long-term condition in themselves. These include, obesity, smoking, use of alcohol and drugs, and hypertension. No. of risk %male Male %female Female Total factors None 6.1% 10, % 15,010 25,412 One 20.5% 34, % 41,554 76,512 Two 29.8% 50, % 46,294 97,111 Three 25.6% 43, % 32,232 75,887 Four 12.9% 21, % 15,800 37,798 Five or more 5.2% 8, % 7,110 15,977 I want to hear my health information from my doctor. I spend a lot of money to go there and I think they should tell me, rather than leaving me to view it on a computer. (Glen Innes Focus Group) 20 Section Two: Building Our Understanding

21 Updated Data on Our local Maori Population Demographic information Maori make up 8.1% of the total Auckland DHB population (approximately 28,000). More than 50% of Maori are under the age of 25. More than half of all Maori live in the more deprived areas of the Auckland DHB region (deciles 8-10), compared to less than 30% of non-maori. Health Needs Analysis for Maori What keeps Maori well often lies outside the direct influence of the health and disability sector e.g. age, sex and hereditary factors, income and employment, housing conditions, urban design, water quality, and education. However, even after controlling for lower socio-economic status, significant inequalities in health outcome still exist for Maori, compared with non-maori. These inequalities are consistently observed in the following areas: the prevalence of risk factors, access and use of services, and health outcomes. Several key Maori health issues were identified in the assessment of Maori health needs within the district. We have been careful in our analysis of need, to balance the negative health statistics for Maori with the considerable strengths and resilience factors which are inherent in Maori culture. We know that resilience factors, such as having a strong identity and sense of self, retaining Te Reo, and being part of a dense social support network, are all buffers against disadvantage. We support whanau, hapu, iwi and Maori communities who have voiced their desire and right to be part of solutions to ensure the wellness of all Maori and the unborn Maori child. The Auckland DHB health needs-assessment data tells us that: Maori are over-represented in mortality and morbidity statistics The most common causes of death among Maori in the Auckland DHB region are cancer, heart disease, circulatory system disorders, and chronic obstructive respiratory disease (CORD) Maori become ill and die from conditions that are largely preventable through good management in primary care The major causes of death among Maori vary according to age group Many of the leading causes of death among Maori are modifiable Maori patients do not appear to access certain tertiary services at the same rates as other ethnic groups Maori have significantly higher perinatal and infant mortality rates A high percentage of Maori hospitalisation rates are for avoidable conditions which can be easily prevented through effective primary health care The collection of Maori health information and access to health service providers is an issue for Maori in the primary health care sector Keep family centres and parent support centres these are life savers. (Western Springs Public Meeting) Primary Health Care Plan for Auckland City

22 Addressing Health Inequalities Determinants of Health The conditions in which people grow, live, work and age have a powerful influence on their health. Inequalities in these conditions lead to inequalities in health. There is a growing body of evidence which demonstrates the importance of less direct determinants of health factors such as income and employment, housing conditions, urban design, water quality and education, as outlined in Figure 1. We want to work with communities, agencies and those organisations whose work also impacts on health, to address health inequalities. Figure 1: The Dahlgren-Whitehead model. SOURCE: Dahlgren and Whitehead (1991). We will address the inequalities that arise from the differential treatment of some groups by the mainstream health system. We know that discrimination does exist in the health system and has become institutionalised over time, exacerbating negative health outcomes. Populations with high health needs There are population groups in Auckland that have significant health inequalities in health outcomes, as discussed above. Maori, Pacific people, South Asia, and refugee groups, have distinct health needs. Inequalities can also be seen when we look at gender and age-related health needs. Auckland DHB recognises the importance of working with these various groups to ensure that services are responsive to their needs which will then contribute to improvements in their health status and a reduction in health inequalities. Pacific Peoples We know from Census 2006 data that Pacific people represent 11.21% of the total Auckland DHB population (approximately 50,000), and that the population is demographically young approximately 50% are under age Section Two: Building Our Understanding

23 Auckland DHBs Pacific population is comprised of several ethnic groupings, which include Tongan, Samoan, Cook Islands, Fijian, Tokelauan and Niuean. Samoan, followed by Tongan, are the two largest cultural groups identified among Pacific people: Pacific men and women have the lowest life expectancy in Auckland (compared to Maori and Other), and for Pacific men this is particularly true if they are in the lower socioeconomic group. In terms of deprivation, Pacific people are the most deprived, with 73% of the population living in the most deprived areas, versus 57% for Maori and 33% for Other. The highest population density areas for Pacific people are in the high deprivation and low socio-economic wards of Avondale- Roskill and Tamaki-Maungakekie. South Asians Our South Asian groups have more recently been recognised as having high needs in general, with high rates of diabetes and cardiovascular disease in particular. Refugees and the Homeless In Auckland we also recognise refugees and the homeless as having distinct needs and requiring targeted services. What Services We Currently Have Auckland DHB is the fourth largest DHB in the country and works alongside five Primary Health Organisations (PHOs). With a population of 428,310 people (according to the 2006 census), it has approximately 10% of the total population of New Zealand. There are 336,064 Auckland City residents enrolled with Auckland City PHOs that is 78.5% of all those people living in Auckland City. As most New Zealanders are enrolled with a PHO, those who live in Auckland City and are not enrolled with an Auckland City DHB PHO, are likely to be enrolled in another metro-auckland DHB. In addition, Auckland City PHOs have a further 95,551 people enrolled who are not residents of Auckland City. Most of these people are likely to live in neighbouring Counties Manukau or Waitemata DHB areas. General Practitioners (GPs) and their practice teams provide the greatest quantum of primary care services. Auckland DHB has a high rate of GP Full Time Equivalents (FTE) (83 per 100,000 population) compared to the national rate (70 per 100,000). Data received direct from the PHOs, shows that Auckland DHB has almost 400 GPs working full time in the city, caring for an enrolled population of 431,615. Primary care practices in Auckland City align to one of five PHOs ProCare Network Auckland, Tamaki Healthcare, AuckPAC, the Tongan Health Society and Auckland PHO. Each has its own philosophy and populations. For example, ProCare Network Auckland is by far the largest with approximately 70% of Auckland City GPs and an enrolled population of 303,000. Tamaki Healthcare PHO, Auckland PHO and AuckPAC PHO are of approximately similar sized enrolled populations (Tamaki and Auckland around 43,000, AuckPAC around 37,000). Tamaki PHO is a Maori-Led PHO. The Tongan Health Society is the smallest PHO at 5,000 enrolees, with a predominantly Tongan enrolled population. Of the 30,000 Maori, most are enrolled with ProCare Network Auckland and with Tamaki Healthcare Trust (54% and 26% respectively. Of the 50,000 Pacific people, most are enrolled with ProCare Network Auckland, AuckPAC and Tamaki Healthcare (46%, 21% and 18% respectively). Primary Health Care Plan for Auckland City

24 To provide primary care services for their enrolled populations out-of-hours, some Auckland DHB PHOs use their Services to Improve Access (SIA) funding to support reduced co-payments with accident and medical centres, while a telephone triage service, and the use of extended opening hours at practice-level, is used by others. The nursing workforce within primary care is vitally important. As an example, in the last twelve months approximately one in six adults saw a nurse without seeing a GP. In a wider sense, the most commonly accessed types of nursing services were: plunket nurses, district nurses, occupational health nurses, dental nurse or therapists, public health nurses and diabetes nurses (refer Auckland DHB Health Needs Assessment). In the future, these nurses will need to be fully supported if we are to meet the anticipated growth in long-term conditions and primary care needs of our population. Many of these nursing services are currently not fully associated with general practice teams. Integration of these services will be essential. As well as this, Auckland City has a total of 119 pharmacies. The wards with the largest populations, Avondale-Roskill (23%), Hobson (20%) and Tamaki- Maungakiekie (20%) are served by the greatest number of pharmacies. Significantly, almost 50% of all scripts are presented to pharmacies within Avondale-Roskill and Tamaki-Maungakiekie wards those wards with the most deprivation. Auckland DHB works with the full range of NGO providers, some of which are funded wholly, or in part, from health, and some from other government-funded agencies. By their nature, NGOs tend to be well integrated into the communities that they serve. Many have been providing services for many years. The range of NGO activity spans a wide spectrum, including health promotion, mental health services including consumer-run services, disability support, child and youth, palliative care, aged residential care, physical activity and lifestyle support providers, and many more. In addition, many non-publicly funded NGOs work with, and in, our communities in response to expressed health and disability need. The Auckland Regional Public Health Services (ARPHS), coordinates and/ or delivers a range of health protection and health promotion services in the city. Hapai Te Hauora Tapui Limited provides Maori public health services and direction. What People Are Telling Us They Want We have received feedback from an extensive engagement process undertaken within the last eight months and amalgamated this feedback with what we know from previous consultations. The following points provide a summary of the key themes that emerged during this process and have helped refine this plan. People are telling us they want: Care that is coordinated between all health care providers. Access to affordable primary health services. Cost continues to be a significant issue. Access to culturally-appropriate care with good interpreter services available. Seamless care for people with long-term conditions. Improved information systems to support booking arrangements that suit people, classification, and usage in primary care. Community-based services for people where they live and work. Better information about services and options available, so that people can be better informed to make choices. 24 Section Two: Building Our Understanding

25 What Evidence Is Telling Us A review of the literature has helped shape this plan. The following information highlights the key points identified in the literature. A strong primary care system is the linch-pin of health care delivery and can help resolve the lack of continuity and responsiveness in health care in general (Saltman and Figueras 1997). Studies have suggested that strong primary care systems are cheaper to operate and their health outcomes are better than specialist-based care systems (Starfield, 1994, Doescher et al 1999, Shi et al 2002 and Macinko et al 2003). Improved access to primary care physicians and their gate-keeping function, have added benefits, such as the reduction in hospitalisation, reduction in the utilisation of specialist and emergency centres, and inappropriate health interventions. Furthermore, evidence from a systematic review suggests that broadening access to primary care can reduce demand for expensive, specialist-led hospital care (Robert and Mays, 1998). There is no one model that works, but Community-Oriented Primary Care (COPC) is seen as useful in the way that it combines population health approaches with primary care (Smith and Ovenden, 2007, Anderson et al, 1998 and Coster and Gribben, 1999). Multi-disciplinary teams (MDTs) are identified as vital to servicedevelopment focused on addressing the management of people with long-term conditions. MDTs and clinical networks are two examples of how organisations can be reformed. There is international evidence of such approaches enabling more effective management of long-term conditions (Wagner EH 2000). Supported self care provided alongside interdisciplinary planned care and population health approaches can improve outcomes for people with longterm conditions (Vale et al. 2002). Neighbourhood approaches to address health inequalities have been criticised, but generally the message from evaluations is that expectations have been very high. The approach is still recommended as a policy (Thomson H 2008). The primary healthcare workforce is ageing and more will need to be done to attract new, younger graduates into the workforce (Ministry of Health, New Zealand, 2008). WHO has identified four key areas of work, which together could maximise the contribution of primary healthcare to health outcomes. These are: (i) universal coverage ensuring health systems contribute to health equity; (ii) service delivery reorganisation of services around peoples needs and expectations; (iii) public policy including the integration of public health with primary care and leadership; and (iv) leadership inclusive participatory negotiation-based leadership (WHO, 2008). It needs to be more than doctors and nurses working together they need to come together over public health and look at the broader determinants of health there needs to be a multidisciplinary approach to health intersectoral work is critical if anything is going to change. (Mt Albert Public Meeting) Primary Health Care Plan for Auckland City

26 Section Three: The Way Forward

27

28 Our Commitments This plan focuses on the provision of primary health care services and activities for Auckland City residents. The NZ Primary Health Care Strategy 2001 states that PHOs are the vehicles through which the NZ government sees improvements being made within the primary health care sector, and therefore, Auckland DHB is committed to working in partnership with our PHOs to achieve the outcomes of the Strategy. In collaboration with our PHOs, we will prioritise the pieces of work outlined below, assess the readiness of potential providers to successfully engage in this work, and submit projects to the Auckland DHB Prioritisation Process for funding and/or seek other means of funding. Any future service development work within the primary health care sector will need to be consistent with this plan. Where these areas of work are new and involve innovation, we will need to build evaluation into new services/ approaches from their start-up. The following section outlines the eight high-level commitments and the subsequent aims and actions that will assist us in offering the people of Auckland City a quality primary health care service that achieves well-being for everyone and forms part of an integrated, total health care system. The Auckland District Health Board Commitments to primary healthcare are to: 1. Empower individuals, their families and communities to achieve better health 2. Work with Maori to maximise their wellbeing 3. Improve the wellbeing of our high-needs populations 4. Establish a neighbourhood approach 5. Support and develop an inter-disciplinary primary health care workforce 6. Provide coordinated services close to where people live, work and play 7. Enable people/whanau to both prevent and live well with long-term conditions (including mental health conditions) 8. Constantly work to improve quality For high-needs population we need to take a stand and ensure they have access to $10 services. (Mt Albert Public Meeting) 28 Section Three: The Way Forward

29 Commitment 1. Objective: Actions: Empower individuals, their families and communities to achieve better health 1.1. To foster a population health approach that explicitly takes account of all the influences on health (the determinants of health) and promotes intersectoral action Trial the introduction of a `health broker or `advocate role to support people through the healthcare system Advocate for the introduction of evidence-informed, universal, and free parenting programmes Develop joint health promotion planning between the Auckland DHB and PHOs Support brief evidence-based interventions in primary care to include smoking cessation, alcohol, drugs, family violence, immunisations, injury prevention and developmental screening Encourage opportunistic health-risk profiling, for example use of cardiovascular risk assessment tools in the relevant age group to determine cardiovascular risk, followed by appropriate education, management and advice Provide adequate support services for people who are attempting to improve their lifestyles Encourage parents to enrol their children in primary care, oral health services and Well Child services Promote the enrolment of older people into PHOs Increase the community health promotion activities available for older people in line with the National Healthy Ageing Strategy Explore options to support primary care to improve immunisation rates Promote and monitor the uptake of cervical and breast screening Promote breast feeding. Provide comprehensive information and in plain language(s) to service users about the types of support services that are available Enable people to access their own information, wherever feasible, in a way which is cost-effective and secure e.g. via web-based access Support the development of internet resources to provide information about illness and where to seek help for people and providers Work with primary care to increase youth-friendly and youth-specific primary care services Increase Auckland City residents participation in health care services, through the establishment of an appropriate forum to discuss healthcare-related issues Explore the use of participatory, rapid-appraisal methodologies to increase the involvement of communities and their leaders in assessing need and planning services Support the development of a range of evidence-based approaches to self management. Primary Health Care Plan for Auckland City

30 Commitment 2. Objective: Actions: Work with Maori to maximise their wellbeing 2.1. To ensure Maori aspirations and solutions for wellbeing are core components of Auckland DHBs primary health care, thereby building on health gain already achieved and reducing health inequities experienced by the Maori population Explore ways to strengthen the Manawhenua partnership arrangement between Auckland DHB and Te Runanga o Ngati Whatua within the primary care sector Ensure Maori Health Action Plans within PHOs are meaningful to their enrolled Maori population we would see these developed and implemented with full participation of Maori at all levels Ensure Service to Improve Access for High Needs Groups and health promotion funding within PHOs, is effectively targeted for locally-oriented and robust services with Maori Explore and implement ways to increase the uptake of funding arrangements for free visits for under sixes, and Very Low Cost Access funding for Maori Continue to build the capacity and capability of Maori-led health providers to deliver appropriate services for all Continue to promote the linking of mainstream services with local Maori networks both formal and informal to assist with health gain, particularly building local/ community programmes, for example, Healthy Eating Health Action programmes sited on marae Develop and implement programmes and services that are based on Maori models of care and that are deemed acceptable and appropriate by Maori Support and resource programmes and initiatives that build Maori community capacity and capabilities and align with the overall aim of whanau ora Work with PHOs to maximise Maori enrolment in PHOs Develop new Maori primary health care services in the most deprived areas within Auckland DHB, including Panmure, Mt Roskill and Avondale, which are attuned to Maori and to the needs of our Maori communities Expand community-based and marae-based primary health care services Work with the primary care sector to further develop Maori leadership (especially clinical) and innovation at a practice level, as well as Maori workforce development initiatives to recruit and retain Maori in primary care Support mainstream providers to ensure their current service models reflect the needs of Maori Develop standard Maori health measurements to track Maori health gain with a focus on long term conditions, but also on areas of potential low utilisation by Maori Collaborate to improve collection and accuracy of ethnicity data in order to improve planning, funding and service delivery for Maori. 30 Section Three: The Way Forward

31 Commitment 3. Improve the wellbeing of our high needs populations Objective: Actions: 3.1. To prioritise activities designed to improve health gain amongst people and populations with high health needs Prioritise those neighbourhoods that have populations with the lowest socio-economic status namely Avondale/Roskill and Tamaki-Maungakiekie Recognise the particular needs of our Pacific communities and how services can be delivered to meet these needs Continue to build the capacity and capability of Pacific-led health providers, as well as supporting mainstream providers to deliver appropriate services for all Recognise the different needs and barriers to access for our South Asian and Chinese communities and ensure services meet these needs Provide more in-depth analysis of our Asian communities Develop primary mental health services that meet the particular needs of our refugee and new migrant community, and in particular, those refugees who have experienced torture and trauma Improve the links between the Auckland Regional Public Health Service (ARPHS), refugee health services, and the GPs who have high numbers of enrolled refugees Work inter sectorally and locally to meet the needs of the homeless Increase our community health worker resource for Pacific, Maori and other high-needs populations Pilot new approaches to case management among our high-need populations who have multiple morbidities Develop a workforce that reflects our multiple communities Explore the barriers to practices committing to very low cost access funding to increase the number of these practices, especially in high-need areas Ensure a level of cultural competence among primary health care providers through the development and implementation of culturally-responsive programmes and resources Develop and implement strategies to ensure we respond to the needs of people, particularly children, who move often or are not enrolled with a permanent primary care provider Explore ways to increase the percentage of children with high needs, who are enrolled with a primary care provider Explore ways to increase the percentage of practices providing free under-six services, through a reduction in the barriers to uptake Work hard to address the barriers to access faced by people who do not speak English, including providing interpreters and information about the health system Reduce the prescription charge for specialist outpatients from $15 to $3, consistent with the Budget announcement Balance potential new GPs establishing within areas of satisfactory/high GP coverage, compared with areas of less coverage Ensure appropriate access to maternity services for high-need groups. Primary Health Care Plan for Auckland City

32 Commitment 4. Objective: Actions: Establish a neighbourhood approach 4.1. To encourage all health and health-related providers to better align these services with primary health care in neighbourhoods Support community action and participation through a neighbourhood approach, as an additional way of identifying needs, service planning and provision Coordinate services in neighbourhoods through PHO leadership Encourage leadership and support within the aged residential sector by establishing neighbourhood hubs, whereby larger facilities support smaller ones with infrastructure such as infection control, training and IT systems Work with local communities and other agencies to ensure services are linked closely through to primary care practices in a particular neighbourhood Continue to support and implement services for Pacific people through the churches (Healthy Village Action Zones initiative) Align public health services to the same neighbourhood where practical Provide a forum where people from community and primary health care sectors can meet to solve system issues Increase collaboration between the DHB, PHOs, NGOs and the community, through shared information, planning, and evaluation of needs In collaboration with key stakeholders, ensure that community services for older people are aligned to work in neighbourhoods alongside primary care teams In collaboration with key stakeholders ensure that community services for children are aligned to work in neighbourhoods and with primary care teams Similarly, examine the interfaces between primary health care services and school nurses to encourage closer ways of working Examine, with the Ministry of Health, funding impediments to this way of working, including clawback and enrolment issues. We like the neighbourhood approach neighbours awhi each other. We like the accessibility of it, it means we don t have to catch a bus to the doctor. (Hui, Mt Albert) 32 Section Three: The Way Forward

33 Objective: Action: 4.2. Develop a neighbourhood focus for primary care practices Work towards ways for primary care practices to meet together and align at the neighbourhood level (probably by ward or subset of ward). An increased focus on teamwork would underpin these networks. These networks would be: Another way for primary care practices to work more closely with other primary care practices in the neighbourhood. An opportunity for primary care practice team members to share specialist, or hard-to-obtain specialised, skills across a neighbourhood, A way to develop clinical leadership across more than one practice. A forum to shape the way services are developed in the neighbourhood. A means to work collaboratively between PHOs to harness their strengths in a particular neighbourhood. A way of PHOs harnessing their health promotion capability to further assist specific communities. A way of practices working more effectively with the local health providers e.g. NGOs, Auckland DHB community services (children and adults), school nurses, Health Village Action Zone Nurses (HVAZ), public health service providers. A way of supporting or enabling the movement of some services from secondary to primary care. These networks would need: To be based on geographical localities e.g. the Auckland City wards. To be incentivised to meet together, and with community and public health providers, to discuss issues for their population and how best to support people whose care they share. The involvement of a lead PHO that could coordinate the network but with participation from all PHOs within that neighbourhood. To have a place for meeting, both informally and formally, that is independent of practices. It may be a place suitable for setting up clinical rooms, where satellite clinics or group sessions could be held. E-Learning technology can also support knowledge sharing and provide a mechanism for on-line meetings/collaboration and training. Primary Health Care Plan for Auckland City

34 Objective: Actions: 4.3. Encourage primary care to collaborate closely with other sectors and with nongovernment organisations at the neighbourhood level, to deliver the best possible services for people who may access both Work intersectorally in neighbourhoods of high need to increase access to educational opportunities Work with schools in neighbourhoods to achieve better health and wellbeing of our school children Participate in housing redevelopment programmes to maximise wellbeing Seek to influence transport policy and facilities to maximise accessibility to DHBprovided services Work with local communities and local government to modify high-injury risk features of the local environment Streamline support to older people remaining in their homes by encouraging agencies providing home support to embrace the neighbourhood approach Promote collaboration between PHOs and NGOs at the neighbourhood level to plan and deliver services where people live, work and grow, in conjunction with their communities Encourage NGOs to make information readily available about the services they provide and how to access these services Encourage NGOs to provide information about local and regional initiatives. I like the use of the word neighbour, rather than community. It feels like something you can touch. Community is a bigger concept. (Glen Innes Focus Group) 34 Section Three: The Way Forward

35 Commitment 5. Objective: Actions: Support and develop an inter-disciplinary primary health care workforce 5.1. To build capacity within Primary Health Organisations Maximise the resources of smaller PHOs by encouraging them to share backoffice functions and explore the option of making this a formal arrangement Work to ensure that programmes do not add to the bureaucratic burden of practices Develop guidelines around the formation of new PHOs/practices to ensure alignment with the NZ Primary Health Care Strategy and this plan Support PHOs to develop their capacity to provide health promotion services Increase the capacity for health promotion practitioners to influence the strategic direction of PHOs Improve primary care capacity to deliver for people living with long-term conditions Ensure that current, and any future, PHOs, operate in a manner consistent with this plan and the NZ Primary Health Care Strategy By agreement with PHOs and local communities, decide which activities across Services to Improve Access for High Needs Groups (SIA Funded Programmes) and health promotion would benefit from a neighbourhood focus By agreement with PHOs, decide the strategic priorities to be worked on in order to generate synergy across the system Support PHOs to review and strengthen their governance and management arrangements in relation to the vision of the NZ Primary Health Care Strategy, including clinical governance Assist PHOs to use the latest population health information to support evidencebased planning Support primary care practices to play a role in maternity care and ensure greater communication between lead maternity carers and primary care practices With PHOs, further develop the cultural competencies of primary care staff. There are great new graduates with brilliant ideas who could work in the health promotion area in clinics and work alongside GPs etc. (Mt Albert Public Meeting) Primary Health Care Plan for Auckland City

36 Objective: Actions: 5.2. Increase nursing and allied health resource in primary care and maximise interdisciplinary working in primary care practices and neighbourhoods Develop a primary care nursing/allied health leadership position Work with PHOs to ensure that all nurses are part of a Nursing Council NZ accredited professional development and recognition programme, including nurse practitioners Develop the full continuum of nursing and allied health roles in primary care, including the continued development of generalist nurse practitioners roles. Foster relationships with education bodies to ensure appropriate alignment with primary care /PHOs into the future Ensure incentives encourage the development of nursing roles e.g. nurse-led approaches to improve outcomes Work towards increasing links between primary care practices, pharmacies, and laboratories at a neighbourhood level Work towards increasing links between primary care practices and allied health professionals at a neighbourhood level or where appropriate Maximise the use of skills and interests amongst primary care professionals at a neighbourhood level, through accreditation and devolution of services from the DHB Support the recruitment of new graduate nurses into the primary care environment Facilitate the development of aged-care nursing through DHB support for a performance development programme Provide on-site support for clinically-complex clients discharged to primary care Explore the options of NGOs and others working within an expanded Primary Options for Auckland (POAK) service to support older people being maintained in the community, as opposed to being admitted to hospital Support post-graduate training in long-term conditions for the nursing workforce Enhance PHO capacity to support primary care teams Collaborate to support the development of practice management capability Maximise the use of skills within DHB community outreach services and integrate these services with primary care Collate information about the independent sector (allied health in particular) and explore ways to work more closely with them to improve health outcomes Explore new ways to attract people into the primary care workforce and the creation of new roles within primary care. 36 Section Three: The Way Forward

37 Commitment 6. Objective: Actions: Provide coordinated services close to where people live, work and play Provide a wider range of services in primary care Implement models of collaborative practice that support the transition of appropriate services from hospital to primary care Improve access to diagnostics from primary health care and develop guidelines to enable direct access to a range of tests such as spirometry, CT and MRI Provide a wider range of services in primary care, which are closer to people s homes, for example devolving minor surgery to accredited primary care practices Explore the option of involving primary care in the provision of pre-operative assessment Work with local communities, primary and secondary care to explore ways to reduce the rates of Ambulatory Sensitive Hospitalisation (ASH) and the need for hospitalisation Examine funding mechanisms to support these changes Explore the contribution that allied health professionals can make to keep people within their local/community settings and promote wellness Increase the provision of quality services where people work and ensure that these are coordinated with primary care. I would use a new health hub if it saved time, meant the waiting time was reduced and was more affordable, especially for children. (Avondale Focus Group) Primary Health Care Plan for Auckland City

38 Objective: Actions: 6.2. Coordinate hospital and primary care services to meet people s needs Reduce the numbers of people not attending appointments through a range of mechanisms e.g. text reminders, links with community health workers, and coordination of appointments for individuals Support the availability of specialists to review or discuss management of people with primary care practitioners and the use of virtual consultations Explore ways to improve communication with people attending specialist outpatient clinics and make the booking notices and reminders more informative around waiting times Work to improve waiting times for specialist outpatient services and consider the use of vouchers for people to access services privately if waiting times exceed a certain amount Explore ways to communicate effectively with people with specific needs who are attending specialist outpatients. We need longer appointment times. At the moment we are lucky to get asked three questions in the time how are we eating, how are sleeping, how we are feeling, and that is the end of our appointment. (Asian Mental Health Group) 38 Section Three: The Way Forward

39 Objective: Actions: 6.3. Coordinate community and primary care services locally to meet people s needs Encourage neighbourhood models of primary care that integrate schools and kohanga reo/preschools Facilitate the strengthening of primary care services to aged residential care facilities, with consistent access and charging, particularly after hours Explore the issues around information sharing and protocols between maternity services and other primary care providers, so as to better meet the health needs of women Work across the sector to ensure that appropriate services are available to women during their pregnancies, including pre-conceptual and antenatal care Encourage analysis of service provision to include the full spectrum of primary care services for women e.g. menstrual problems, contraception, pregnancy and childbirth, breastfeeding, maternal mental health, infant health, teenage pregnancy, infertility, sexual abuse, domestic violence, incontinence and aging. I am concerned that wards are created by statistics and that might not be the best way to set it up the community. (Mt Roskill Focus Group) Primary Health Care Plan for Auckland City

40 Objective: Actions: 6.4. Ensure that information systems support knowledge transfer for people and providers and improve communication and coordination throughout the health system Improve the collection and use of information so that where the person has consented, information about them is shared between their health care providers. This would include sharing of aggregated non-identifiable information for planning purposes to improve service provision. For example, information gained in working with a community could inform how health promotion could be better provided, or how we could address non-financial barriers to service Improve communication between primary and secondary care, so that all health care providers in the region have access to health event summaries about the people they are caring for. This means that appropriate information (for example, lab tests results, discharge summaries and dispensed medications) should be readily available to authorised personnel in both primary and secondary care Ensure that information transfer from secondary to primary care (for example, clinic letters) occurs electronically Encourage the development and use of a population health analytical tool in practices to support proactive planned care Work to ensure that referral criteria are incorporated into the workflow of primary care practitioners Implement a regional electronic referrals system, so that referrals can be made via standardised referral forms, referrals are acknowledged upon receipt and triaged in a timely manner, and referrers have current information on the status of their referrals. Explore innovative approaches to referral that include a higher level of primary care assessment and decision-making Improve the quality and timeliness of electronic discharge summaries Work collaboratively between practices, PHOs, and the DHB, to ensure that reporting requirements for programmes are simplified Create a regional repository for dispensed medications and examine the implementation of web-based prescribing, accessed by GPs, pharmacies and hospitals to reduce or eliminate prescription errors (in accordance with the key directions action zone) Work to ensure that referral criteria are incorporated into the workflow of primary care practitioners by advancing Electronic Decision support processes Work collaboratively between practices, PHOs, and the DHB, to ensure that reporting requirements for programmes are simplified Use a range of methods to contact people attending clinics, including and text Work collaboratively with our partners on minimal guidelines for practice management systems and support primary care practices to meet these guidelines e.g. around coding and call/recall systems Consider options for a regional electronic patient record Implement information systems that provide for comprehensive monitoring of services to children, to ensure that they receive appropriate services at the right time, e.g. immunisation. 40 Section Three: The Way Forward

41 Objective: Actions: 6.5. Ensure that primary health care services are available to people around the clock and in the weekends Work with key stakeholders to ensure that out-of-hours arrangements are equitable and sustainable, and we are working through these issues with all parts of the local health sector Maximise resources within the healthcare system to improve access Investigate ways to address after hours provision and home visits for high-needs groups. Primary Health Care Plan for Auckland City

42 Commitment 7. Objective: Actions: Enable people/whanau to prevent and live well with long-term conditions (including mental health conditions) 7.1. Re-orient services to improve the prevention, detection and management of long-term conditions within a life-course approach Implement a Long Term Conditions Framework (see framework in Appendix 2), that supports self-management, reorients the health care system, and harnesses community resources to better prevent and manage long-term conditions Ensure information systems are supportive of an integrated approach to longterm conditions Promote and advocate for models of care that ensure we provide opportunities to involve families/whanau in health care for people with long-term conditions, acknowledging the influence many women have in promoting healthier lifestyles and food preparation Enhance the ability of primary care to assist older people, and people with disabilities, to remain in their own homes as long as possible Ensure that people with palliative care needs have access to the appropriate generalist support in the community Encourage the development of comprehensive screening, treatment and review practices that include workplace locations Work in collaboration with key stakeholders to increase district nursing involvement in the management of people with long-term conditions, and palliative care in particular, in line with the recommendations of the recent palliative care needs assessment Acknowlede that people with long-term conditions often have mental health needs, and ensure that primary mental health services are available for these people. We need to work smarter - we need brokers in the health system. (Mt Albert Public Meeting) 42 Section Three: The Way Forward

43 Objective: Actions: 7.2. With our PHOs, shape the provision of primary mental health services to provide universal coverage, as well as meet the needs of targeted groups Implement the recommendations of the Primary Care Mental Health and Addictions Plan (see Appendix 1) Work with PHOs to focus activity on early intervention in the mental health arena, particularly engaging with high-need groups. These groups include new mothers, isolated elderly people, and people with disabilities, as well as high-need groups outlined earlier in the plan Support initiatives such as Progress Plus to better integrate services across the primary-secondary interface and provide better physical health services for people with severe and enduring mental health and addiction issues Encourage PHOs to work more closely with NGOs working in the mental health and addictions sector, so as to work in a better integrated way for consumers Develop a consistent set of indicators to assess improvements in care provision for the services provided. Primary Health Care Plan for Auckland City

44 Commitment 8. Objective: Actions: Constantly work to improve quality 8.1. Ensure primary health care services are delivering high quality care to their populations Support the development of the Primary Care Clinical Advisory Group to provide clinical leadership for quality in primary care, also linked to wider DHB activities Undertake a stock-take of current quality-improvement programmes Review the use of Primary Options to highlight areas for quality improvement at the primary-secondary interface Provide feedback to PHOs and practices about their performance on priority issues Explore the development of additional indicators within primary care that would reflect improvement, and could then be utilised to become a local expanded version of the current PHO Performance Management Programme Explore the option of a sentinel event reporting system in primary care Increase the use of guidelines at the primary-secondary interface Consider a more systematic approach to generic prescribing Encourage the analysis of data to review outcomes on equity of access, alongside the emphasis on clinical safety and effectiveness Develop strong and effective relationships between primary care and research institutions Support primary care with resources in the DHB, where appropriate, for example, infection control Ensure that complaint systems are clearly understood, implemented, and acted upon. I would use a new health hub if it were an after-hours service that didn t cost any more than a normal work-hours service. (Avondale Focus Group) 44 Section Three: The Way Forward

45 Primary Health Care Plan for Auckland City

46 Section Four: Evaluating Our Progress

47

48 What Does Success Look Like? To assist us in evaluating our progress, we have summarised key points, which are outlined below, so that we know when the system is working as we intend. The critical outcome measures we want to achieve over the longer term are: Healthier communities and environments Equity between groups of people An integrated, whole system approach; and Health benefits for individuals and their families/whanau We believe that success includes: A strong primary care system as the linchpin of health care delivery. It will act as the driver to coordinate people s health care across the whole system. People accessing primary care to determine what they need to keep themselves and their families/whanau well, as well as when they need to access more specialised health care services. This will result in fewer hospital visits for our population overall, and fewer inappropriate interventions. People having easy access to information about services, fees and provider performance. A range of primary care services available, so people can have choices according to their culture, language and other needs. Strong multi-disciplinary team-work, as well as all disciplines used effectively. Primary care services showing a much greater coordination and integration, to better meet physical and mental health needs, as well as shifting the focus towards population health and health promotion as appropriate. Our primary and secondary services functioning as if they were one system, with substantive links to NGO services. A broader scope for PHO services,with greater community participation in primary health care services. A population health approach that sees the primary care workforce involved in addressing wider health determinants such as community capacity-building, and partnering with education, justice, housing, and local government. This broadens the concept of working in a team to include health promoters, collaboration with planners in local areas, NGO community workers, and other community-based health providers. In time, our communities having an improvement in health status, particularly those in our communities with high health needs whereby their health status will indicate the reduction/removal of current health inequities. People being able to access primary health care services out-of-hours in a primary health care setting. The hospital emergency departments will not be considered primary health care services by default. We need services with a Maori face and Maori feel. (Mt Roskill Hui) 48 Section Four: Evaluating Our Progress

49 We want tangible results so we will develop an outcomes framework that builds on our capacity to measure progress in primary care service provision. Measures are likely to include: Screening cervical, breast, and others. More people will have issues detected within primary health care at an early stage. Targeting best practice and outcomes. Better management of health issues/ events within primary health care and better prevention of issues where we can most influence prevalence rates. Evidence of good collaboration between primary health organisations, secondary care services, non government organisations, allied health, and other health and support services. Evidence that we are reaching our high-needs groups, particularly reducing inequalities in service areas. Collective wellbeing and whanau ora. Evidence of increasing/improving the capacity and capability of our primary health care workforce. Improved population and patient satisfaction measures. The outcomes we want over the medium/long term are: Effective coordination and communication across the health care system, including information provided for people and their whanau to better access services. Hospital waiting times that are consistent or better than national averages. Improved access to diagnostic services. Further reductions in barriers to accessing primary health care services, for example, cost and transport. A system that promotes resilience among individuals, communities and families. Alignment of financial incentives to providers to support good quality service provision. Improved interdisciplinary approaches to support team work. Robust and effective workforce measures for recruitment and retention. Information systems that support primary health care, especially primary/ secondary integration. We want whanau services from baby to nannies i.e. full whanau services in one facility. (Hui, Mt Albert) Primary Health Care Plan for Auckland City

50 Section Five: Who has been involved?

51

52 The Working Group Alison Leversha, Community Paediatrician, Auckland DHB Barbara Stevens, Chief Executive Officer, Auckland PHO Caroline Ogilvie, Project Manager, ADHB Celia Palmer, Clinical Leader and Working Group Chairperson, Auckland DHB Deirdre Maxwell, Manager PHOs and Primary Care, Auckland DHB Diana Good, RNZCGP Facilitator, Mt Eden GP, GP Liaison Auckland DHB John Paerau, Tihi Ora MaPO Jude Keys, Executive Officer, ProCare Network Auckland Leani O Connor, Pacific Health Planning and Funding Manager, Auckland DHB Linda Fletcher, Health Information Manager, Auckland DHB Linda Kensington, previously Executive Officer, ProCare Network Auckland (now Waitemata DHB) Nadine Maloney, Primary Health Care Nurse Educator, Auckland DHB Neil Hefford, GP, Grey Lynn Medical Centre, and Director, ProCare Network Auckland Nikki Turner, GP, Director of the Immunisation Advisory Centre, University of Auckland Sonia Rapana, Primary Health Care Nurse Educator, Auckland District Health Board Tania Waitokia, Programme Manager, He Kamaka Oranga, Maori Health, Auckland DHB 52 Section Five: Who has been involved?

53 The Steering Group The Steering Group were combined sessions of the Primary Health Organisation (PHO) Forum and Primary Care Clinical Advisory Group (PCCAG). PCCAG Membership Celia Palmer, Clinical Leader and PCCAG Chairperson, Auckland DHB Deirdre Maxwell, Manager PHOs and Primary Care, Auckland DHB Barbara Stevens, Chief Executive Officer, Auckland PHO Barnett Bond, GP Liaison, Auckland DHB Glennis Mafi, GP, Tongan Health Society Jim Kriechbaum, GP Liaison, Auckland DHB Karen Hoare, Nurse and Lecturer, School of Population Health, Auckland University Lorraine Stevens, Clinical Manager, Tamaki Healthcare PHO Maree-Ann Jensen, Community Pharmacist Mukul Diesh, GP, AuckPac PHO Neil Hefford, GP, ProCare Network Auckland Ngaire Kerse, Associate Professor, School of Population Health, Auckland University Nicki Brentnall, General Practice Liaison Nurse, Auckland PHO Russell Smart, GP Liaison, Auckland DHB PHO Forum Membership Barbara Stevens, CEO, Auckland PHO Jude Keys, Executive Officer, ProCare Network Auckland Linda Kensington, previously Executive Officer, ProCare Network Auckland Paul Lavulo, CEO, Langimalie, Tongan Health Society Tereki Stewart, CEO, Tamaki Healthcare PHO Winston Timaloa, CEO, AuckPAC PHO Primary Health Care Plan for Auckland City

54 Engagement with Partners Academic GP group (School of Population Health) Accident and medical clinics Allied Health Forum Auckland DHB GP Liaison group Auckland DHB Information Technology Team Auckland faculty of RNZCGP Auckland Regional Public Health Service Community Child Health and Disability Services Community health workers Community pharmacies GP focus groups Independent physiotherapists Individual GPs (including Doctor magazine, direct and via PHOs) Maori health Margaret Horsborough (Academic Nurse) Ministry of Health Primary Care Team Pacific health Practice nurses (including Kai Tiaki magazine) Primary Health Care Nurse Leaders Reference Group meeting ProCare Health Limited Public health nurses School of Population Health Secondary nursing Selected ADHB primary care practices Tamaki Healthcare allied health providers Tihi Ora Mapo Community Engagement to Date Between October and December 2007, seven community focus groups (total of 84 people) were held around Auckland City (Glen Innes, Glendowie, Onehunga, Mt Albert, Avondale, Waiheke and Ponsonby). In addition, nine people with longterm conditions were also interviewed individually. Additionally, five focus groups in Avondale, Grey Lynn, Glen Innes, Mt Roskill and Remuera (total 48 people), three hui (at Orakei Marae, Ruapotaka Marae and Fickling Centre, Mt Roskill), one formal meeting with Te Roopu Kaumatua o Wairaka, and two public meetings, were held at the end of September, Section Five: Who has been involved?

55 Written Feedback Received Age Concern Alcohol Advisory Council of New Zealand Auckland City Plunket Auckland PHO Auckland Regional Public Health Service Auckland Women s Health Council BirthCare Auckland Eating Difficulties Education Network Glenn Innes Diabetes Support Group He Kamaka Oranga, ADHB Kathy Peacock (CHADS) Ministry of Health Primary Care teams Pacific Health, ADHB ProCare Health Ltd ProCare Network for Auckland Safekids School of Population Health Bruce Arroll, Karen Hoare, Pat Neuwalt, Sue Wells Sport Auckland Stroke Foundation Stroke Foundation Northern Region Inc Tamaki Healthcare PHO The Phobic Trust of NZ Inc Tihi Ora MAPO Women s Health Action Trust WONS: Nursing, Education and Health Promotion Services ADHB Provider Arm David Spriggs, Dianne Rogers, Janice Mueller, Jill Sye, Michal Noonan, Roger Jarrold, Taima Campbell, Te Puea Winiata, Tony Baird, Wendy Cook, GP Liaisons. Planning and Funding Team ADHB Carol Stott, Elizabeth Bennett, Julie Helean, Karen Holland, Mazin Ghafel, Paul Bohmer, Lisa Gestro, Linzi Jones, Sarah Marshall, Stephanie Muncaster, Tony O Connor, Wendy Hoskin. Allan Moffitt Counties Manukau DHB Individuals: Chris Sai Louie (occupational health nurse), Danny Stewart (Clinical Director, General Paediatrics, SSH), Jenine Clift (primary mental health nurse specialist), Jim Burdett (Mind and Body consultants), Jordan Salesa (physiotherapist), Lorna Murray (AMHS), Nihinihi Wirihana-Welsh, Sara Rishworth, Zena Rombouts. Primary Health Care Plan for Auckland City

56 Appendices

57

58 Appendix 1: Doing more in primary care to help people with mental health and addiction issues The diagram is adapted from Our Lives in 2014, the Blueprint and the Strengths Care Plan. It shows a person surrounded by all the social supports and health services they need for good mental health. This is what we want for people resident in the Auckland District Health Board area. A continuum for good mental health Auckland District Health Board (Auckland DHB) wants to provide services across the full continuum of mental health and addiction issues. While funding in the past has been restricted to people experiencing serious mental health and addiction issues, we also need services for people whose issues could be described as more mild to moderate. One of the best ways to reach people at the very early stage of issues, is within primary care services. This plan focuses on wellness, on prevention, and early intervention a stance that is consistent with the DHB imperative to Lift the Health of People in Auckland City. We want all parts of the health care sector to prevent issues and to help people regain wellness when they are unwell. This plan: provides the direction we need to identify and help people experiencing mild to moderate mental health and addiction issues in the primary care setting helps primary care providers (doctors, practice nurses, school counsellors, etc) to identify and respond to mild to moderate mental health and addiction issues helps to build better links between primary care and secondary care for people experiencing serious mental health and addiction issues A large number of mental health and addiction services are in place already. Some are within primary care practices, although the largest number are specialist mental health and addiction services for people experiencing serious mental health and addiction issues, with specific services for Maori, Pacific people, Asian, children, youth, and older people. These help people to live as independently as possible, and with a good quality of life. 58 Appendices

59 The priority groups for new funding are those who carry, or are likely to carry, the greatest burden, including: Maori Pacific people Children Young people When funding is available we will: Invite Primary Health Organisations to put up proposals for projects aligned to the aims of this plan Encourage non-government organisations, allied health, and other health and support services to work with Primary Health Organisations to extend the primary mental health and addiction services available for the groups above. This means that Auckland DHB is not prescribing what the services should look like. We think the best ideas and innovation will come from our local community-based services. An RFP (request for proposal) will be issued when we have funding confirmed. All new work in this area will need to be undertaken with an evaluation component built in from the start. Any future service development work will need to be consistent with this plan for primary mental health and addictions. The outcomes we want over the medium term are: Resilient and healthy communities Strong and resilient families and whanau Prevention and early intervention services focused on mild to moderate mental health and addiction issues Primary mental health and addiction issues prioritised Improved collaboration and links across the health sector, and other sectors, on primary mental health and addiction issues. New services could include: First point-of-contact for issues (widely accessible, and not necessarily sited within the traditional primary care context) Assessment/triage (by people with appropriate skills, or with input from people with appropriate skills) Range of services appropriate to assessed needs Support for recovery Health promotion Primary Health Care Plan for Auckland City

60 Appendix 2: An integrated approach to the prevention and management of long term conditions. Long-term conditions have been described as the healthcare challenge of this century. The World Health Organisation estimates that globally 60% of all deaths are due to long-term conditions. Over the next ten years, the number of deaths attributable to these conditions is projected to rise by 17% (WHO 2005). Longterm conditions are the leading cause of death in New Zealand, and account for more then 80% of the deaths. The most common conditions by diagnosis in New Zealand are:- chronic neck or back problems (one in four adults), mental Illness (one in five adults), asthma (one in five adults years), arthritis (one in six adults) and heart disease (one in ten adults). Others such as stroke, diabetes, COPD, and chronic pain, are significant in terms of the burden of disease. Obesity can also be considered as a chronic condition. Nearly all these conditions have disproportionately high rates among Maori and Pacific populations. Poor people too, have higher rates of chronic conditions and fewer resources to manage them. They are the leading cause of preventable morbidity, mortality and unequal health outcomes (Ministry of Health 1999). Many people with long-term disease have more than one. In the UK it has been estimated that 45 percent of people have more than one long-term condition. Older people comprise a significant proportion of people with a long-term condition. There are increasing levels of co-morbidity and complexity of long-term conditions associated with ageing. Maori and Pacific people, as well as people from Southwest Asia, have a disproportionately higher incidence of these conditions as well as earlier morbidity and mortality (Ajwani et al 2003). The common themes in the management of long-term conditions are the following: there are often opportunities for either primary and/or secondary prevention management includes the motivation of people to self-manage the healthcare professional needs to be proactive about seeing or contacting the person/family it is necessary to enlist the help of a multidisciplinary team the gap between the evidence and practice the risk factors are the same and therefore people often have more than one communication and continuity of care are both key to good management. To date there has been no strong commitment to these common themes in the development of chronic disease management (CDM) as it has generally been called. Traditionally, disease specific programmes are developed and implemented, possibly as these fit most closely with secondary-care models, where the professional expertise is considered to reside. This work breaks new ground in starting from a different way of thinking, where the similarities listed above are considered most important, and the disease or condition is of secondary importance. The approach has more in common with primary care approaches to health, which tend to focus holistically on the complete needs of a person. It also ensures both physical and mental aspects of the person s health are considered, an approach that fits more closely to Maori models of health. This framework outlined is based on the premise that primary care doctors and teams are attempting to provide best care for people with long-term conditions, but that the system is not supporting their attempts to do so. This framework, again, is a shift in thinking from the current state, which starts from the premise that primary care doctors and teams do not have the knowledge to provide good care. Instead, it is suggested that the best care is not being implemented for a variety of reasons, of which knowledge is only one factor. 60 Appendices

61 Other issues that may be of more significance are lack of client motivation, barriers that prevent clients from engaging with planned care, lack of multidisciplinary team approach, lack of doctor time, lack of communication between health care providers etc. It is thought that previous attempts to improve the management of long-term conditions have under-delivered, due to a lack of consideration of whole system (cross disease, cross professional etc.) approaches as described above. We will be proposing work in the four work-streams identified in the framework, namely self/whanau resilience, strengthening community participation and action, empowering primary care, and reorienting specialist support (including integrating with primary care). Where appropriate we will use collaborative quality-improvement techniques to implement change. The first step will be a system-wide workshop, bringing key stakeholders together. Primary Health Care Plan for Auckland City

62 References Anderson RJ, Pickens S, and Boumbulian PJ (1998) Toward a new urban health model: moving beyond the safety net to save the safety net resetting priorities for healthy communities. Journal of Urban Health: Bulletin of the New York Academy of Medicine Coster G, Gribben B (1999) Primary care models for delivering population health outcomes. Discussion paper for the National Health Committee. Doescher MP, Franks P, Saver BG (1999) Is family medicine associated with reduced health care expenditures? Journal of Family Practice 49: Macinko J, Starfield B and Shi L (2003) The contribution of primary care systems to health outcomes within OECD countries Health Services Research 38(3): Ministry of Health (2008) Working Together for Better Primary Health Care. Roberts E, Mays N (1998) Can primary care and community-based models of emergency care substitute for the hospital accident and emergency department? Health policy 1998, 44: Saltman RB and Figueras J (1997) European Health Care Reform: analysis of current strategies. Copenhagen: WHO Regional Office for Europe Shi l, Starfield B, Politzer R and Regan J (2002) Primary care, self-rated health and reductions in social disparities in health. Health Services Research 37 (3): Smith J, Ovenden C (2007) Developing integrated primary and community health services: What can we learn from the research evidence? A report for Counties Manukau Health Board. Starfield B (1994) Is primary care essential? The Lancet 344; Thomson, H (2008) A dose of realism for healthy urban policy: Lessons from area-based initiatives in the UK. J Epidemiol Community Health : Vale MJ Jelinek MV, Best JD, Santamaria JD (2002) Coaching patients with coronary health disease to achieve the target cholesterol: a method to bridge the gap between evidence-based medicine and the real world. Randomised controlled trial. J Clin Epidemiology 2002;55: Wagner EH (2000) The role of patient care teams in chronic disease management. BMJ 2000 February 26:320(7234) World Health Organisation (2008). The World Health Report. Primary Health Care. Now More Than Ever. 62 Appendices

63 Notes Primary Health Care Plan for Auckland City

64 THE TONGAN HEALTH SOCIETY (Inc) Ko e Sosaieti Tonga ki he Mo ui Lelei Private Bag Auckland Mail Centre Auckland 1142 New Zealand